- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,454.71
| Facility | | $1,202.26 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,412.54
| Professional | | $954.99 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,621.81 / $1,905.46
| Professional | | $794.33 | $1,621.81 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $2,041.74
| Professional | | $870.96 | $1,096.48 | $2,041.74 |